MEDICARE: DEMARIO JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1104241744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMARIO JACKSON

Provider Business Mailing Address
First Line	:	4909 EL ESTE LN
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-5596
Country	:	US
Telephone Number	:	702-572-8404
Fax Number	:

Provider Business Practice Location Address
First Line	:	4909 EL ESTE LN
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-5596
Country	:	US
Telephone Number	:	702-204-1781
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	03/05/2014

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Directions to “ DEMARIO JACKSON ” Practice Location

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